Project Summary/Abstract Multi drug-resistant tuberculosis (MDR-TB) is a growing concern with increasing morbidity and mortality particularly for HIV-positive patients. The HIV/TB epidemic co-exists alongside increasing rates of cardiovascular disease (CVD) and related risk factors such as hypertension and diabetes. The dual burden of infectious and non-communicable disease leads to a unique pattern of multi-morbidity, the presence of 2 or more chronic diseases. MDR-TB/HIV co-infected patients are particularly vulnerable to diseases such as hypertension or diabetes which increase cardiovascular risk. Few studies have explored multi-morbidity focused on CVD risk factors among patients with MDR-TB/HIV co-infection. The purpose of this study is to characterize the multi-morbidity of CVD risk factors among HIV and MDR-TB co-infected patients and to determine the association of CVD risk score, estimations of the burden of multi-morbidity, and social determinants of health with MDR-TB treatment outcomes. This proposed study is a secondary data analysis of a large cluster randomized controlled trial of nurse case management to improve outcomes among MDR-TB patients in South Africa [R01 AI104488-01A1, PI: J. Farley]. The specific aims among the HIV-positive subset of this MDR-TB protocol are: (1) to determine the prevalence of CVD risk factors (e.g. diabetes, elevated BMI, smoking and hypertension) along with the frequency of elevated CVD risk score; (2) to explore the impact of individual and combined CVD risk factors such as diabetes or hypertension on 6-month negative treatment outcomes (i.e. death, loss to follow-up or treatment failure) through sub-group analysis; and (3) to explore the association of multi-morbidity to 6-month negative treatment outcomes. This project is guided by a modified WHO Innovative Care for Chronic Conditions model specific to infectious and non-communicable disease multi-morbidity. Secondary data analysis will be completed for the MDR-TB/HIV co-infected subset of patients enrolled in the parent study by March 2017 based on study variables collected by the parent study. A non- laboratory CVD risk score validated in a South African population will be the primary measure of CVD multi- morbidity burden. This study will help to better describe the prevalence and impact of CVD multi-morbidity on this already vulnerable population of MDR-TB/HIV co-infected patients. It is aligned well with the Office of AIDS Research NIH priorities to understand co-morbidities among HIV patients and the NINR strategic mission to improve health outcomes and health services. This training plan will begin a program of research designed to understand the complex interactions between conditions such as HIV, TB, and CVD risk factors from a socioecological framework and develop interventions to improve the lives of this patient population.